APPLICATION PACK BURJ DAYCARE NURSERY

APPLICATION PACK BURJ DAYCARE NURSERY

Child s Name: This application form must be fully completed and the necessary documents provided before a child can start at nursery. Child s Details Child s name: Passport number: Issue date: Date of birth: Expiry date: Country of issue: Attendance Information Please attendance type required. Annual Attendance Normal Day: 8am 12.30pm Full Day: 8am 2.00pm Extended Day: 8am 4.00 pm Flexible Attendance Hourly: Daily: Weekly: Monthly: Payment Type Cash: Cheque: Bank Transfer: Page 2 of 11

MEDICAL AND IMMUNIZATION RECORD UPDATE Please complete all sections of this Medical and Immunization Record and Consent Declaration. It is mandatory that this declaration be received prior to your child commencing at. The information provided will be treated as confidential. Name of Child Class Nationality Date of Birth Gender (Please circle) Male / Female Home Telephone # Father's name Mother's name Father's Mobile # Mother's Mobile # Alternative Emergency # Contact Name Family Doctor/Clinic Name Doctor / Clinic # Has your child suffered from any of the following? (Please ). If yes, please indicate the date(s) under the 'Yes' box. Illnesses Yes (Date) No Conditions Yes (Date) No Chicken Pox Diphtheria Infective Hepatitis Measles Mumps Poliomyelitis Rheumatic Fever ADHD Allergies/Eczema Bronchial Asthma Congenital Heart Disease Diabetes Mellitus Epilepsy / Seizures Febrile Convulsions Page 3 of 11

Illnesses Yes (Date) No Conditions Yes (Date) No Rubella Scarlet Fever Tuberculosis Whooping Cough Frequent Headaches Frequent Gastric Problems Hearing Problems Nocturnal Enuresis Other Thalassemia/G6PD For any 'Yes' responses, please provide more details, including treatment, dates and any medication taken on a regular basis..... Note: If your child commences any new medication, treatment, or changes his/her existing medication, the Nursery nurse must be informed accordingly. Family History (Please the appropriate box) Diabetes Hypertension Stroke Tuberculosis Others, please specify: Name of Parent and Signature:. Date: Page 4 of 11

Certificate of Immunization Kindly indicate the date immunization was administered under the appropriate columns, and attach a photocopy of your child's immunization record for verification. Type of Immunization 1 st Dose 2 nd Dose 3 rd Dose Booster Remarks BCG BCG Screening Hepatitis B DPT Polio Hib Measles MMR D.T. Chicken Pox Rubella Others The Department of School Health requires that the Nursery maintains current information of each child's immunization history. Therefore, it is important that this form is fully completed. If you have taken the decision not to vaccinate your child, you will be requested to sign a letter to this effect to be included in your child s health records. I confirm that this is a true record of my child's immunization history. Name of Student: (Please PRINT) Name of Parent:. (Please PRINT) Signature: Date Page 5 of 11

CONSENT FOR THE ADMINISTRATION OF MEDICATIONS As the parent/guardian of (PRINT child s full name & Date of Birth), I give my consent to the following: In the event that my child develops a fever, pain and allergy, or he/she has injured him/herself, it may be necessary to administer some medication or treatment. I have read and understood the list of the medications or solutions used at the Nursery. No other medications other than those identified below and those prescribed by a doctor will be administered. Any exceptions to this must be agreed to by our nursery doctor and subsequently authorised in writing before administration can be allowed. In this case, I will accept that the administration/application is undertaken at my own risk. If my child is unable to use any of these medications, I will contact the Nurse to discuss the use of an alternative. This is to authorize the nurse to administer the appropriate drugs for the various situations, subject to the notification that an alternative be used. Name of drug Age Dose Indication Remarks Adol 120mg/5ml 1-4 years 15mg/kg/ dose Pain, Fever Repeat after 4-6 hours Fenistil Gel All - Allergy, Insect bite Every 8 hours Fenistil Drops 1-4 years 1 drop/kg Allergy, insect bite Every 8 hours Saline Nasal Spray/ Drop All 1 Puff/ Drop in each Nostril Blocked Nose As required Arnica Ointment All As per instructions Mild Bruising/Sprains As required I consent to my child being given any of the above, should it be considered necessary by the Nurse. Name of Parent:.. (Please PRINT) Signature Date Page 6 of 11

CONSENT FOR EMERGENCY TREATMENT In the event that my child requires emergency treatment, I will be contacted and asked to collect my child from the Nursery. If the Nursery is unable to contact me, my child will be taken to a doctor or hospital for diagnosis and treatment. Efforts to contact me will continue. I consent to my child being taken to a doctor or hospital in the event of a medical emergency. Name of Parent and Signature: CONSENT FOR NURSERY MEDICAL EXAMINATION The nursery health programme is a screening procedure of well children, aimed at detecting any abnormalities or defects which might need medical intervention. Dubai Health Authority (DHA) requires medical examinations of children in nurseries and schools. The process of the medical examination is to screen all body systems, including examination of chest, heart, abdomen, skin, eyes, ears, throat, musculoskeletal, nervous system and assessment of growth and mental development. The Nurse will be present for the duration of all examinations. The results of the examinations are documented in the child s Health Record. Any findings requiring additional follow up or referrals will be reported to the parents using the Clinic Visit Form. Only students for whom we have received written parental consent will be assessed. If you have any queries or concerns regarding this examination, please contact the Nursery nurse. I, (Please PRINT) consent do not consent please tick as appropriate for my child (Please PRINT) to be examined by the Nursery doctor. Name of Parent and Signature Date Page 7 of 11

BURJ DAYCARE NURSERY INFECTION CONTROL POLICY In order to reduce and minimize the spread of illnesses in the Nursery the following regulations shall apply. 1. Please do not send your child to the centre if they have: A fever. A skin rash. Vomiting (not to return to nursery for 24 hours after the last vomiting episode). Diarrhoea (not to return to nursery for 24 hours after the last diarrhoea episode). A persistent cough. A heavy nasal discharge (Note: For children with a small cough and/or a clear nasal discharge, they will be allowed to attend class). Red, watery and painful eyes. 2. If they have an infected sore or wound, it must be covered by a well-sealed dressing or plaster. 3. If your child is assessed by the doctor and/or nurse, and deemed to be a possible source of infection to other children, you will be contacted to take them home immediately. Please inform the Nursery if your child has been or is being treated for a medical condition. I have read and understand the above Infection Control Policy. Name of Parent and Signature:. Date Page 8 of 11

DIETARY INFORMATION Please note that the Nursery is a NUT FREE environment. Special dietary requirements? Yes No These requirements are due to: an allergy? a preference? Where there is an allergy situation identified an allergy questionnaire must be completed. Please indicate the requirements below: Vegetarian Halal Lactose intolerance Dairy Wheat Gluten Nut..... Please note any other requirements or restrictions we should be aware of:. Name of Parent and Signature:.. Date Page 9 of 11

GENERAL PERMISSION FORMS CHILD RELEASE / PICK UP (OTHER THAN PARENTS) We hereby authorise the below-named to pick up our child from the Nursery: 1 NAME: RELATIONSHIP: 2 NAME: RELATIONSHIP: 3 NAME: RELATIONSHIP: EMERGENCY CONTACT DETAILS If, as a parent, I cannot be contacted please contact the person/s identified below: 1 NAME: RELATIONSHIP: 2 NAME: RELATIONSHIP: 3 NAME: RELATIONSHIP: Name of Parent and Signature:.. Date Page 10 of 11

PHOTOGRAPHY RELEASE FORM I give permission for my child to be photographed by Nursery staff members or Nursery appointed photographers during the academic year, including but not limited to class photos, individual photos and activity photos such as sports day, concerts, etc. I understand that these photos may be used for my child s Learning Journey, in monthly newsletters, on nursery display boards, on the Nurseries Communicator, on our website and Facebook page. These photos may also be used for advertising and marketing purposes. Please cross this section out if you do not wish your child to be photographed. During the academic year, group and individual photo packages will be taken by a private photographer and made available to parents for purchase. I understand that I am under no obligation to purchase those photos and I will make a decision at that time. DECLARATION BY PARENT / GUARDIAN The Nursery reserves the right to vary or reverse any decision regarding the child s admission or enrolment made on the basis of incomplete, untrue or inaccurate information. I/We have read, understood and agreed to the contents of this form. All information provided is complete, true and accurate, with no false statement or misrepresentation. Parent / Guardian Name & Signature Date Page 11 of 11